the newly formed IMG track here at the APA, meaning that looking at IMG issues from an IMG perspective, from a medical school orientation, from GME, residency and fellowship orientation, and then moving it along into the CME as reflective of the post-residency practicing psychiatrist perspective on this issue. And why? Because we know that the issues are. So, we look forward to an engaging, interactive discussion. Again, this is a big room with a lot of echo, but—oh, you are recording it? Thank you. I'll be careful what I say, too. None of the presenters have any relevant financial disclosures, either, and this is a brief outline of the roadmap of what we want to do today. So, the learning objectives are in your—as you see on your app and if you've downloaded the PDF in your handout, it's there. One is to provide a brief overview of the current state of not only the workforce, but IMG specifically, then look at the different pathways through the whole continuum of professional development with a focus on education, and then leading into specific resources and support for IMGs as they go to advance their education at each point, at each of these main proverbial forks in the road of professional development. So, on that note, I'll turn it over to Dr. Justin Singh, who will take on this next portion. Thanks. Good afternoon, everyone. Well, there you go. Echo, echo. So, I realize around this time that everybody's attention spans are getting a little, you know, you're mentally exhausted. If we were in Florida, we would enjoy some Cuban crack together, which is a small amount of entirely too much high-density caffeine mixed with entirely too much sugar to keep you along the way. But instead, I'll try to be as colorful as I possibly can to keep your attention. So, we're going to start with talking about the active psychiatrists in the United States. So, the U.S. Bureau of Labor and Statistics, as of May of 2022, they identified 26,500 active psychiatrists that are working in the United States. That's excluding psychiatrists who are in private practice, who are self-employed. And I actually just attended Dr. Madan's IMG perspective lecture, and he identified the member with ERAS as 56,000 active psychiatrists. Of the active psychiatrists working in the United States, IMGs represent 29%, and in this realm, in comparison to the other subspecialties, we are of a higher percentage than the other subspecialties, which is 23, which is what you see up there. But not all IMGs are made the same way. So, we have two different tracks of international medical graduates, one as United States citizens who are international medical graduates and non-U.S. citizen IMGs. And if you look at the numbers, the non-U.S. IMGs, they take over a large proportion of that 29%, around 22%. And so, of the non-U.S. IMGs, we see that India and Pakistan produce around 30% of those active psychiatrists who are practicing today. So, just a slide, a couple slides on identifying the differences in trends with U.S. IMGs and non-U.S. IMGs. We can see when it comes to the active workforce that non-U.S. IMGs more commonly pursue subspecialties than U.S. IMGs. And in some subspecialties, to the tune of three times the amount in addiction psychiatry, and four times the amount in geriatric psychiatry. And when we look at this one, this number is a little bit more staggering, where you see the different areas that psychiatrists are working, and you can see the numbers speak for themselves, right? Non-U.S. IMGs are the life force of hospital systems. They tend to take hospital appointments. They tend to train residents. Some of them semi-retire versus completely retiring. They get involved in administration more commonly. They produce more research commonly. They teach in medical schools more commonly. They attend locum tenens more commonly. Whereas U.S. IMGs typically secure office-based private practice. So, we have a mental health crisis, and we need more psychiatrists. I think everybody in the room can agree upon that. Now, since 2013, there have been 130 new psychiatry programs that have come up and have produced 300 new psychiatry residency positions. So, the trend, though, is that we have decreasing IMG matches into psychiatry. So, in 2010, the number was around 25% for international medical graduates graduating. In 2013, we got a peak of just around 30%. And this graph only goes up to 2020, but the data from 2023 shows the number is similar. 16% in 2023. And of that 16%, 6.9% were non-U.S. IMGs. And so, the number that we have of non-U.S. IMGs is dwindling. Those IMGs that are fulfilling the hospital systems. Those IMGs that are pursuing some specialties. And so, you can identify the trend that's happening here. So, in speaking about that, these are the IMG match rates for PGY-1 positions over from 2014 to 2020. And the darker the region, the more concentrated the IMG match. And as you can see, we have in central regions of America, we have a lot of concentration of IMGs who are practicing. And less so in the coastal regions. Now, when we compare it to the active psychiatrists that are working in the United States, we can see this number, the same rule applies. The darker the color, the more concentrated the amount of psychiatrists. So, if we look at the coastal regions, you can see that there is a concentration of psychiatrists. And you can see the lighter regions are showing that the central regions of the United States are less concentrated. So, when we put this data together, what does it tell us, right? IMGs are fulfilling roles in areas that are not as attractive to American medical graduates. And the data shows that non-US IMGs stay. So, what that means is non-US IMGs are more likely to locate to a rural area, treat, and also the poor patients in the population, they're more likely to give their career to. So, this is a staggering worry. When we track this out, if we are having less non-US IMGs matching into our system, we will have less of an ability to fulfill the mental health needs of the areas that we're seeing here, right? So, numbers don't lie, right? And we're seeing a declining trend before we even get a foot in the door. In ERAS applications from 2018, we had 3,300 or so applications. And our numbers for IMGs dwindled significantly to currently where they're around 1,800. So, that's almost a 50% drop. So, actually, in talking about this, Dr. Madan, who is the chair of education at the APA, he discussed how, when we track this out, it's a worrisome trend. Because if we don't have the IMGs who are going to be fulfilling the roles in the public sector, who are not pursuing the subspecialties, then we're going to have a drought in the ability to be able to deliver quality of care equally among the United States nations, right? The whole nation. States are going to have differential care, and it's going to cause a difficulty in mental health parity. So, Dr. Saul Levine of the APA, he's the CEO and medical director, he reported that mental health is now on the national agenda. Of course, after COVID, we know that this is obvious, right? And it's been in a way that it's never been before. Our profession is critical to meeting the needs of the country. We have a lot of elder psychiatrists who are going to be moving into mental health care. We have a lot of elder psychiatrists who are going to be moving into retirement soon. And we have a bottleneck in the amount of IMGs who are coming into our system to provide care. So, the projections show that I've seen different numbers. This number is 12,530. I've seen numbers that are up to and around 16,000. By 2030, which is not far away, to see that we are going to have a disparity here that will lead us to worsened quality of care. So, the goal here is to provide all realms of the pursuance through psychiatry, from medical schooling to residency to early career psychiatry, and to help you all, to provide you with resources. Because I am an international medical graduate. I am a non-US IMG. I took three years to get into the system. And three years where we are a vulnerable population. A vulnerable population that can be exploited. And that there is so much information out there in the internet. It's hard to know where to go for adequate and quality information. It's hard to know how to navigate in American culture and be able to proficiently be able to do so to achieve success. And so we're hoping in this group that we'll be able to provide some of these resources that will help everyone moving along in their stages in their careers. So, Dr. Castellanos mentioned all of the different areas, right? The UME, which is the undergraduate medical education, so that's our medical students who are trying to get into residency. Our GME, which is our residents who are doing their best to flourish within their residency programs. And then the CME, which is early career psychiatrists trying to figure out as US IMGs, as non-US IMGs, where their place is in the world and where to go from here. So, I'm going to pass over to Dr. Orozco who will talk about the UME and I'll be back for CME. Hi, everyone. So, as Dr. Singh mentioned, we are here a panel composed of IMGs, US IMGs. So, when we say undergraduate medical education or UME, it's usually what we refer to as medical school, and it's comprised of medical students that are preparing to enter into residency. So, usually as IMG, we have to take into account the potential barriers that we face because whether we study in a system that is not focused on preparing you for the US MLE, which is the licensing exam that we require to practice here in the United States, or any other potential limitations, such as, for example, most recently, the STEP scores. STEP 1, which was used as the first filter, and was something that international medical graduates are using their advantage to put themselves in a competitive position when they started. You can hear me now? So, now that the STEP 1 transition to pass or fail, that puts us in a difficult situation because now we have to rely heavily on other scores, such as the STEP 2CK, or even the STEP 3. So, all the limitations that we face also are issues regarding US immigration, such as the visa, language and communication also might be a huge factor that we face as IMGs, and cultural issues, getting used to a different culture. So, we're going to discuss also in the break rooms what resources we can use to use it in our advantage in the process of transitioning from medical school to residency. So, these are whether we follow different pathways, such as when you're a US IMG and you go into a foreign medical school, or whether you are a non-US IMG. There are different obstacles that you might follow. So, graduate medical education, that's when we usually are already into residency. So, what are the obstacles that we can face? The biggest one that I personally found was getting used to a different culture. That's one issue that happens a lot between residency, because usually if you... For example, you march into Miami, that has a huge Hispanic population, and usually Spanish is the main language you're going to talk with your patients, and you're not proficient in Spanish, and you're going to have to get used to learning a new language, and those are usually potential barriers that you can face. So, these are things that you have to discuss and you have to take into account when you're in residency, and what possible solutions that you can use to work with them. And those are the things that we're going to discuss a little bit later. And as a US IMG, when you're in residency, there are also different pathways, whether you are a US IMG or you are a non-US IMG, and whether what is your plan for your future, for example, where you're pursuing a fellowship, or whether you're transitioning into the workplace. It's going to depend. When you're going into a fellowship, usually you're going to face more or less the same obstacle that you faced when you were transitioning from medical school into residency. It's going to go into an hour cycle of a matching program, an hour cycle of looking for places where you want to pursue a higher education. And when you decide to transition into the workforce, usually those are different obstacles, whether you want to, you're a non-US IMG and you require a visa, or whether you transition into, I mean, you've been a student your whole life and then you are an IMG, you're in a different culture, you have to take into account where do you want to practice, and what type of practices you want to do. And then we're going to Dr. Singh again. Back again. So at this point, right, you made it. You're through residency, you're an early career psychiatrist, and you have all of these challenges that you're facing, and they're differential based off of whether it's a US international medical graduate or a non-US IMG, right? I think the major one that I've heard, I've attended most of the IMG lectures that have been here throughout the weekend and into today, and I think immigration is a major, major, major issue. It is difficult to be able to sort of navigate this process without knowing really what your restrictions are, how to move through the system. And I think Dr. Orozco mentioned also, you know, on a J-1 visa, it has to be renewed every single year. You have restrictions on when you can go and visit your family to be able to get a stamp to come back into the country. After you've completed your residency, you're kicked out of the country for two years, right? And if you don't know how to navigate through that process, whether it be through a Conrad 30 waiver or whether it be through an HHS waiver, you know, it's difficult to be able to know where you're going to land and where you're going to be. And oftentimes, you know, hospital systems may utilize your immigration status as a negotiating tool, which affects everything underneath, right? It affects your workplace environment, where you're going to work, and not only where you're going to work, the quality of the work in which you are going to be able to do. I have heard stories about doctors who have signed in with contracts, who are being forced to prescribe medications that they're not comfortable with, who are uncomfortable with supervising nurse practitioners and physician assistants, who are seeing an ungodly amount of patients per day because that's the cap that they require, and the visa being held over their head in a manner in which to be able to keep them in the workforce. And so it also affects your salary, so contract negotiation is all embedded into this, right? We also have lives outside of medicine, right? Some of us are parents, some of us are, you know, are spouses, and we are connected in different ways. And when you're an early career psychiatrist, you have been functioning off of between $45,000 to $60,000 a year for yourself or your family, and so typically you move into a space now where you're earning in the top 5%, and how to navigate through that process, how to know, you know, hands up anyone here who has gotten any financial training in their medical school, to be able to know? Hands up if you've gotten any idea about contract negotiations, you know? Hands up if you had any immigration knowledge of these things within the schooling system? None, right? So these are things that IMGs are left to figure out on their own, and it becomes very, very difficult. You know, student debt. I mean, everybody has it. How do we manage it? What are the opportunities that we have available to us to be able to reduce down that student debt? So we can talk about different loan repayment programs, the public service loan forgiveness, the HRSA GREDs, and I think one of the things that I've learned in being at this meeting is that connections are incredibly powerful, right? Incredibly powerful, and I had the fortunate opportunity to meet a lot of people in the IMG caucus, and if you don't know what that is, I really suggest that you pursue looking up the IMG caucus and seeing some of the resources that they have. There is no better way to figure out your landmark in this space other than gaining a good mentor, and being able to gain a good mentor will help you with the trajectory of what you plan on doing for your career, and what are your opportunities available, and more often than not, the mentors that are here are incredibly highly accoladed, and so I think it's important to impress upon you all the importance of having somebody who is later on in their career who can offer you the opportunities and thoughts, maybe outside of what you thought you were going to do, maybe within the same realm, or maybe if they don't know, they definitely know someone who does. So those are the things that I would like to talk about in the continuing medical education component of this. So we have a tight-knit group here. Can I get a raise of hands, who's medical students here? All right, so we have a few residents, fellows, we have a few early career psychiatrists. All right, in the transition. Okay, so because we have a smaller group, I think one of the things that we wanted to do is break out into smaller groups to discuss particular needs of everybody, but if you would oblige us, it's probably better for us to just get together and talk about these issues as a collective, right? So of course we have a couple of different topics we can talk about, but it'd be nice to have some engagement. If there are any burning questions that anybody has that may have been inspired from this lecture, Dr. Uplapati. Yeah, so that's a good question, and it's something that's been brought up quite a bit. We've had an increase in the amount of American medical schools that have opened up. We've had an increase in the amount of DO schools that have opened up. So that brings added competition, as of course we know AMGs are going to be preferred for residency match positions. That's one of the issues, and I think also as you've seen, the trending, especially after COVID, was we had a lot more difficulties with the immigration just due to the backlog and the challenges of being able to figure out this J-1, this H-1B, what does it all mean? I think that's a major thing, and I'll also say that some of the other countries that are in dire need for trained psychiatrists have been farming from the United States, and so a lot of the restrictions that Australia had have been reduced to allow for pathways for doctors who've been trained in the United States to get in. Canada has done the same thing. The UK have done the same thing. So I think we're seeing a lot of our trained doctors moving into other areas, and also, I mean, let's talk about the continuum, right? It's medical students, it's residents, and doctors. We are seeing a lot of medical students applying and having more success in some of those areas, and so I think that's where we're starting to see the disparity, and it's concerning because, like I said, in the areas, US IMG countries in general are providing care in places that American medical graduates don't want to go, and if we stop doing that, the model is going to change to accommodate for the need, and so we've seen an increase in psychiatric nurse practitioners in applying for independent practice. We've seen challenges where there is a disconnected system, and a lot of places trying to fulfill needs in areas just due to the fact that they don't have the experts. So yeah, I think it's a, thank you for the question. Also, this training was seen after the pandemic, and we cannot forget the economic impact that the pandemic brought to all of us. We all know IMG, how expensive could be all the process for application to a residency, and who can afford, after a pandemic, coming to our service, paying for all the applications, the immigration process could be, but I'm not sure if there has been some research or a study regarding that topic, but could be like a possible scenario. Medical students around the world are less in a less favorable position to apply for a residency in the United States, and to do all the process that we know. So medical students, who knows where you can find an observership if you wanted to go and say, hey, I want to apply to a residency, and I want to do an observership here in the U.S. Where do you find those? I'm sorry, maybe some platform or website like? Clinical Nexus, is that a pay-to-play website? No, okay. So you would go to Clinical Nexus and say, oh, I am a medical student in blank, and I want to go do an observership in the U.S., and therefore I would go to Clinical Nexus, and there's a list. I'm sorry, remember, this is being recorded, so please, please come, microphones. I had my own experience with Nexus. It's very similar to Veslo, but they were asking a lot of information and requiring a lot of documents, so that was really hard for me to get that observership. I was applying to Larkin Community Hospital at that time, and I had a really rough time getting all the documents to the website due to technical issues. So that was my way to trying to get an observership, yeah, okay. Hello, so when I want to do an observership, I just go to the Google and see what type of program has this, and then enter to the program and being like a stalker, and then, you know, get the information. But no one told me about what opportunities we have as an IMG. Okay. I haven't done it myself, but from other students, I've heard that you could also contact the doctor, specific doctor you want to work with, but a lot of them won't reply, so you just have to like message a lot. A lot of networking, right? Well, so we expect by September that on the APA IMG website, we have developed that a resource guide for you, and that'll have a list right now. It's at about 10 or 12 with all the detailed information where you can try for the clinical observerships and about another 10 or 11 for research observerships, but that's exactly one of the challenges, right, that you're out there fishing and connecting, right? Yeah, so Dr. Orozco mentioned, right, that the Step 2 CS no longer is something, right? Now, if the Step 2 CS is not there to validate my ability to competently interview a patient and make a differential diagnosis in a plan of care, then how are these programs going to know that I am going to be of that clinical awareness? And I think that observerships can definitely help you. One thing I will say is that observerships can yield you very quality letters of recommendation, right? But also remember that observerships are not technically clinical experiences, right? And so I have mentored a lot of graduates who have not yet matched into the American system yet who have done observerships after observerships after observerships and they've applied and they have four letters that are quality letters, but they're all observerships. And so because of that, your clinical competency is lower. The program directors are looking at when you graduated and from then the time starts, right? After the first year, you are 50% clinically competent. After the second year, you are 25% clinically competent. After the third year, zero. So one of the ways that you can get around this, if you have the money to do so, is to engage in some companies who offer externships. These companies offer you malpractice insurance and they guide you through and the professors who provide the letters of recommendation, they specifically say that the clinical experience meets the six ACGME core competencies and those are the words that need to be said in order for it to be considered a clinical experience. Now, I would also say that observerships within the realm of the hospital system that you're working can add to your benefit, right? And the more observerships that you have, like I said, it kind of works in the favor of the Step 2 CS where it says, okay, listen, I have six months of observerships. My clinical competence in being able to speak with patients and in psychiatry, the good thing is we don't have to get our hands dirty, right? We just have to use our ability to communicate and I would guide those who are pursuing observerships to essentially ask the supervising psychiatrist to specifically talk about interpersonal communication skills in the letter because that is one of the most important core competencies when it comes to an IMG. Have all the students passed their Step 3s? That's another good point, Dr. Castellanos. So the two-second version is the application process is a three-tier process, right? Don't practice your interviews because if you can't get in the door, the interviews come later, so it's tiered, but that with what's called applicant inflation, with a tremendous increase in the number of applications, psychiatry as was shown earlier, and the use of Zoom where you don't have to spend time to travel, it becomes a real statistical thing. So if you have already graduated, we call that discontinuity, there's an expectation that you will have passed Step 3 before you're even considered on that first pass of the pre-screening of all those large number of applications. Then on the second tier of the phase of that is where they take a deeper dive and look at the contents of the application including all those things that are in those rubrics, right? Like the number of observerships, your clinical experience, your work experience, your research experience, your scholarly activity, your LORs, your letters of reference, your personal statement, and needless to say, you're fit for the program, right? Oh yes, I'm applying to Idaho. Have you ever been to Idaho? No, I haven't. Well, what makes you think you want to be here and all that? And then the third phase is the interview where all that gets integrated as well. So you need to start with Step 3 because all those other things are great, but if you don't have Step 3, you will be screened out. There's a good resource on the NRMP website where program directors, they respond to surveys and the data is collected and presented in wonderful graphs specific for each subspecialty. I suggest everybody goes to the NRMP website to look at those things. In psychiatry, especially as a postgraduate finishing with graduation, USMLE Step 3 is something that you just should do. It gives the program the confidence, one, you usually need to complete Step 3 in the first year of your program, and so that's a barrier that you've automatically removed, right? I haven't looked at the program director's survey in a while, but the last time that I did, the USMLE Step 3 wasn't as important in terms of the numbers, but when you're finished with graduation, you want to put your best foot forward in the most strong way that's possible, so you try and complete everything that you possibly can. And I also say that, you know, one of the mistakes that I made as an IMG was I applied to 15 to 10,000 programs, I peppered my application all over the place just hoping for a wish and a dream, right? So focusing in a region, in an area that you are intending on practicing, I think that's important, and for, you know, US IMGs, I think that that answer is a lot easier because, you know, you're a US citizen, your family is in a place already, your home is in a place, so it's easy for you to be able to just apply into that area, that geographic region, but for non-US IMGs, you could technically go anywhere, right? So you remember the blue map, right? So we want to increase our chances in places, right, where the match rate is high for IMGs, but still in those areas, it's very difficult to match into the system, so, you know, there's a balance of trying to figure this out and making sure that you're, if you're committing yourself to a place, you're committing yourself to a place for enough of time for them to be confident you're gonna stay. Most programs, they want to hire doctors who are going to provide in the area that they're practicing, right? So that's definitely for consideration, and also for non-US IMGs, it's really good to have a US address on your application. Any other questions? So one of the things I think, in terms of the realm of residency, right, I was talking with a chief resident who's in Boston who suffered from a lot of difficulty in being able to acculturate, coming from a strong Indian background and trying to figure out American culture was a difficult thing, and oftentimes this resident felt excluded from a lot of events within the residency program due to the fact that they were different, they didn't understand the culture, and so one of the things I thought was really cool was a resident who was part of her PGY class paired up with her and taught her the, you know, American culture 101, right? First, go to a football game. Two, scream at the football game, right? Be very passionate about what you're doing. Understand, you know, music, listening to the radio, these days, you know, TikTok, Instagram, social media, and what that means. I think those are all things that are difficult when you're coming from another culture to really understand, and these are things that you are required to learn. One of the things that, again, I'm referencing some of the other lectures that I went to with some of the kings in IMG here at the APA, and they speak about the incredible resilience of IMGs. You know, it takes sometimes years to get yourself into success, and it's not an easy task to face disappointment year after year, to get an email year after year where your world is crushed, and to identify a sense of hope to continue on and continue to move forward. I think that's why we see the numbers for non-US IMGs so high in subspecialties, so high in the public sector, because there is a need to make purpose to suffering, right? And when you make purpose to suffering, that's when you, that's when you, you heal yourself. So, you know, within, Dr. Castellanos is telling me to stop talking. For the medical student, are you trying to apply sooner for the residency? One advice, are you familiar with the timelines for the application process? Okay, that's something that you have to be very clear, that everything has a time frame, that your application has to be ready, you have to be ready for that, that implying a lot of things. You have to get your certification, your ESF-IMG certification, you have to have all your documents legally processed in your countries to be able to apply, and that's something that you need to know, what is the time frame for the application, the timeline, the deadline for everything, if you are trying to apply in a certain period of time. Also, you can take advantage of these programs such as FRIDA, or all these programs that have the database that can let you know, like, or allow you to apply smart, because as Dr. Singh said, that was also one that I applied to every program in psychiatry in the United States, and it became a burden economically-wise, because it was by the time that we were still doing interviews, and you know, all these places, you're gonna notice that you're not gonna be a good fit, so it's very important for you to tailor your search into, is this an IMG-friendly program, what's the main population that the program has, like, what's the culture, am I gonna feel comfortable here, so that's something that you can take into account. Also, you can always talk to your peers, like, older classes, or they're already residents, that match into specific programs, and you can ask them, like, hey, how is this program for you, like, because that's something that you can use in your events. I've seen, like, this is a program that has a couple medical graduates from this school, and maybe I'm a good fit here, maybe they're like a very IMG-friendly program, and I'm gonna feel comfortable here, so those are the things that you can use, and programs such as FREDA helps you doing that, and also, I strongly believe that by the time I was using FREDA, they were also, like, allow you to know which program, like, rely heavily on steps, or what scores, or what is the trend, or the, usually, the average of scores in the, between the residents. So, how about a question to stimulate discussion? We've been doing a lot of talking, right? How about you all, right? Besides Freida, do you know any other resources that can help you choosing the programs? Yep, AMC has a great website, and by the way, yes, that whole resource guide will come out on your APA website, too, including the non-professional part, like Dr. Singh was mentioning about life, adjusting to culture and life in the United States, so it'll have a whole component on that as well. I have a question. Is there going to be any kind of membership for the International Medical Group that will be part of the APA? I'm sorry, say that again? Any kind of... I know what you're talking about. Dr. Acosta's mentioning, I think Dr. Hastianos, you're a part of this, that the International Medical Graduates have completed their medical schooling, right? Can you speak about that? So, we just got that approved today in the membership committee. We sit on the membership committee, and then we're presenting it to the board, so that there is this undefined group where someone graduates from medical school, but they haven't entered into residency, so as of now, there is no membership category for individuals who have graduated from medical school, but have not gone into postgraduate medical education yet. So, we will be, if it gets approved by the JRC and the board, now at the end of the month of next month, they will create a separate category that will be extension of medical student for three years only, right? So you can't be a graduate for 20 years and say, I want to be a member of APA, to allow individuals be members and access resources like these meetings where you get coaching, you get information, you get access to both peer and vertical mentoring and resources, et cetera. So that will be coming, and that will be beginning in the fall as well. What are your needs? What are the questions? Talk to us, people. Come on. Yes. Thank you for answering all our questions. I have a question regarding signaling. Do you have any advice on signaling and how we can use it to our benefit? I can answer that, right? So this is what we do for a living, right? So program signaling is relatively new. It's now in its third year. Not every program has to participate in program signaling. It has two components. One is geographic preference, where an individual applicant signals a preference for a certain geography, like, hey, I want to be in the southeast, in the mid-Atlantic, the western, the middle states. And then secondly, it's signaling a variety of different values and attributes and other things that would help identify the individual applicant's alignment with the residency program. So if you say, oh, I want to do all this research, and then the program doesn't do all this research, it's going to be a misalignment, right? Now what's not clear and what the data is just starting to emerge is where that information gets used. Is it used on the screening? Is it used for the actual reviewing of the applications? Is it used for deciding who to bring in for an interview? Or is it used for the ranking? In reality, it's used for all of that, but the early data is suggesting that signaling, which is the secondary app, is being used differently by different programs, and it's not really clear at what phase. A lot of them are using it for deciding who to bring in for interviews and how to rank that person. Hi. I have a question, two questions, actually. First one, I'm just curious, does APA have a mentorship program? So one of the things, so remember, mentorship, what we found out in surveying all the IMGs was that mentorship has value, has different value depending on the area of one's professional development, right? So when you're older, you say, yes, okay, that's important, but really for medical students and RFMs, resident fellow members, it has a different value, and that the value is different, right? And especially ECPs and some resident fellows really value more peer mentoring as opposed to older mentoring. So what does that mean? That yes, you can find a senior person, but that there's value in meeting as part of the IMG caucus with other individuals that are part of, in similar situations as you. Right now, obviously, medical students, it's all very vertical, and so it's not, there is this informal, but where it's, so take a step back. The APA this year, because of the importance of this institute and IMG track and all the SPC, the Scientific Program Committee, so that's why you see all these presentations, including esteemed colleagues here. And as part of that, what's going to come up is probably a more formal mentoring program for IMGs specifically. And then next, what's being looked at, which is what we discussed today, was about more for general from minorities and underrepresented groups in general. So it's coming. And that mentoring will probably have a form of coaching, which is what we're trying to help you with here now, right? Not just go down some cognitive list and say, do this, look at this, but practice, ask questions, be more coached, which is a more active process and not just a cognitive process. And it's bi-directional, right? It isn't just us talking to you. So that will be coming, but not yet. Thank you. And the last question, I am a US IMG, and I'm going to be a year without matching because of my school. What do you recommend me doing that year? There's a number of things that you could do. Have you completed step three? No. Number one. And where were your rotations at? Miami. University of Miami? No, Larkin and Carol T. Hospital. OK. So my suggestion to you would be to leverage your position in the place that you're in, right? So I would continue to maintain the relationships with people that you've had within those experiences. I would, the Florida Psychiatric Society is part of the APA. I would definitely suggest that you network there. One of the things that I wanted to say after Dr. Castellanos finished was, you know, I think that mentorship is something that can happen in multiple different ways. You right now speaking allows for us to have an engaged conversation where we can share information, right? And so, you know, people who are on the opposite side of this get to see your passion in the nature in which you ask questions, right? So just by being at the IMG lectures, for me as an early career psychiatrist, it's opened up opportunities in multiple different realms for IMGs and specific with the APA and beyond the APA. So I think that, you know, the answer is not a linear answer, but there's several different things you can do. Observerships is definitely one to maintain your clinical competency. Those are the two things. Definitely getting the step three done will help you. And, you know, externships, sub-internships in the area would help as well. Thank you. Remember, please, that it's a tiered process, right? So the very first step, you will be screened out of over 95% of programs if you don't have step three because of what's called discontinuity, right? If you're in medical school, you're not going to be eligible to take it, so it's not going to be required. But the great majority of programs, if you've already graduated, want you to pass it. Now, forget how the score, right? It makes you more competitive, but that's part of the screening. And as you've heard, because of IMGs being more concerned about how competitive or not, it's that term applicant inflation because they get thousands, each program gets thousands and thousands. There's over 21 residency programs in Florida. There's 140% in PGY-1 slots in the last 14 years. So there's a proliferation of programs, but the competitiveness remains, as Dr. Singh mentioned. So you need to focus on your first goal, and so it's passing your exams. Obviously, you can't go back. Your GPA is already done. But being recognized, because that gets you in the door, being familiar with the program that you've done. You did an audition, rotation, or an externship, or et cetera, et cetera. That'll get you in the door, and then past that prescreening, it's all these other wonderful things, right? Definitely. And the letters of references, that's part of your rubric. If you want to get more points to be ranked, you want to make sure the individuals that write those letters know how to write letters of reference. Yes. And so therefore, sometimes we'll just do a word count and go, gosh, there's only like three small paragraphs, and everybody's smart. This is a smart individual. It's like, everybody's smart. How does that help? And the two big domains are either attributes or accomplishments in there, right? What is the person's attributes? Oh, and they were fixing the air conditioner because it broke in the little clinic. And then what were the accomplishments? And then comes the next tier of things, like who it's from, where they're from, who are they, and all those things. So you've got to focus on that first part of getting in the door and getting past the prescreening. Yeah. The quality of the letter, when the letter was written, the date on the letter, if the letter's coming from the chairman of psychiatry who is also the program director that carries power. Based upon my experience of evaluating this many students, Dr. So-and-so is within the top 5%. That's a great statement, right? But Simon Sinek says people don't buy the what, they buy the why. And so I had a letter of recommendation where essentially a doctor wrote out my CV. And that is the driest letter of recommendation that you can get, right? So if your supervisor is able to talk about something specific, a case that you shared, I think that that's something that would carry a lot of value. And focusing on the six ACGME core competencies, which is where another person gets to talk about your why and speaking in the language that program directors like to hear. Speaking on this topic, I'm applying this year for residencies, and I was wondering, would you advise, I ask my recommenders for the standardized letter of recommendation or the traditional one? What would be more preferable for this cycle, at least? We don't have, if you go to certain other specialties, they do have the slow and EM, and it's a standard letter of recommendation. And we do not have consensus across the country on that, right? So it really depends. And so in a way, in my mind, it doesn't matter. It's the quality of the letter and not the formatting. And that's, again, very important, right, what you're doing. And back to what you were saying, if you have discontinuity, it's what you're doing, right? If you're saying, hey, I'm working at Walmart, that's great. God bless you. But if you're saying, hey, I'm working as a scribe, and I am looking, I am studying for Step 3A, and I'm doing research over here and all that. So right now, there is no consensus nationally on that for us. In other specialties, yes. So it goes back to the quality of the letter. And remember, in those rubrics that all those things get evaluated, you get more points, right? And you've got to get the points in order to be ranked, and then you've got to be ranked in order to be accepted. So it's qualitative. I think research is definitely a good one to help bolster, especially if it's clinical research, for sure. I remember an application, you know, novel things stand out, right? One medical student who spent time while they were studying for the Step 3 after they graduated, working in the mental health hotline and answering, you know, being able to, you know, utilize that time to show that you still have a continued interest. Maintaining, maybe, you know, getting CBT certified in the Beck Institute. Maybe moving into different things that will help to bolster your application. And, you know, everything's changing, right? Once your application gets into human hands, having a strong social media following where you're talking about medical or mental health can be significant to help. You know, a program may look at that and say, well, they have a strong social media following. This will help to enhance our exposure as well. It's definitely chest, not checkers, right? Who knows what encompasses scholarly activity? The broad category, scholarly activity, what does that include? Come on, guys, we're trying to get participation here too, right? Scholarly activity. What falls under the broad umbrella of scholarly activity? Well, Dr. Singh mentioned one, research, right? What else? Presentations. And, you know, that hierarchy goes from presentations at international meetings and national meetings like here, regional, state, to local. Why? Because you get more points the more. So presenting at an APA presentation, like that big poster, that big-ass poster you have there, right? You can get more points in your scholarly portfolio. What else? Research presentations. Publications. And then in that hierarchy, peer-reviewed publications, book chapters, and then non-peer-reviewed publications. Forget the impact of the journal and all those other things, but publications. What's that? Volunteering? No, volunteering would be... That's a separate domain. And then the others include really hard things to do, like I have scholarly-related service activities, like, oh, I am volunteering to be an editor for this journal. I'm on the editorial board of this journal, right? I have national service, which none of us have on an NIH research committee, but it's part of scholarly activity, right? So it's a continuum of different activities, right? So you pick and see what you can do, starting with engaging in scholarly activity to enhance your competitiveness. And it's the same thing in residency, right? Because what happens after residency? You've got to apply for a job or a fellowship, and you want to enhance your portfolio. And even to that note, when, you know, you start out with scholarly activity early and you get PubMed IDs under your name, it helps you in the immigration process in becoming an expert. More doors open for you if you're looking for an H-1B visa, if, you know, being able to have enough publications and aggressively, you know, presenting posters and being involved in research while you're in residency. If you're on a J-1 visa, it bodes well for you to increase your amounts of exposure in the research realm because then it solidifies you as an expert, and it increases your opportunities to pursue different things like an O-1 visa, H-1B. You know, there are more opportunities that I've learned about here. And, you know, I'll tell you, the more meetings that you come to physically and you put in the groundwork, the better you are, you know. Also, locally, right, we have, you know, coming to the APA is definitely a place where you can enhance your exposure. And then moving specifically into IMGs, you know, attending the IMG caucuses, meeting with and asking questions after the sessions are done with some of the supervisors. I think that goes a long, long way. If you're applying in psychiatry, how many people are members of the APA? Is everybody here? Not everybody. Okay. But if you're applying, it does help. And this is... Sorry. This is not... Give credit to your reviewers, right, when you submit applications, that they know. If you sign up, like, the week before you submit your application, it looks like a shameless, transparent attempt to kind of, we call it, inflate your portfolio, right? Whereas if you have shown, expressed this longitudinal commitment to being a member of this or that or your district branch, right, every area... APA requires dual membership, right? So you have to be a member of APA and the local district branch and your geographic area of residence. So that's another thing that helps. So be involved in your district branch and be a member. Okay. Go for it. Let's go. Where are you? I have a question regarding legislation. Are there any... Is there any legislation at the moment that you're aware of that it's in favour of IMGs, something to look forward to in the future? Dr. Castellanos, do you want to...? No, there isn't. And actually, there's a lot of legislation No, there isn't. And actually, state-by-state, there has been attempts, right? And, for example, in Florida, there was an attempt to allow Cuban physicians, for example, to be able to practise without passing all those exams at some point. But that's a state-by-state issue. Nationally, I do not believe there's any national... Even with the workforce misallocation that Dr Singh was referring to and the need, no, because then the push, when you talk about scope of practice, has been to have other professional groups fill those voids and say, oh, we're nurse practitioners. We can do that, or we're PAs, or we're prescribing psychologists. So, therefore, then, there hasn't been that much of a push to kind of have these kind of legislative things to facilitate as much. Tennessee just passed, five to six days ago, for licensed psychiatrists in other areas to practise in Tennessee and work on a restricted licence for, I believe it's two or three years, and then after that, you can have an unrestricted licence. And I think Missouri is also another area. Missouri is one. Right out of medical school, you can practise in Missouri. Yeah, so I think, you know, getting exposure, you know, in those places, you know, passing step three, and then right after that, you know, if you're a non-US IMG, it's likely that if you go to Missouri and you start to work, it enhances your chances of being able to get into the programs that are in the area. And then... So these are all avenues that weren't available from before that are offering opportunities. When I graduated, I couldn't even become a phlebotomist. Anybody experience any discrimination in any other residency programs? When you are trying to find observer shapes or set up rotations and you reach out to programs Usually they don't reply when they find out that you're an IMG. However, like friends that did Also email and they were like US medical students. They would get replies So I do think there is a bias towards us, unfortunately Absolutely So the discrimination of patients, of doctor, of dog and everything is really high in some city I'm living in Chicago right now sometimes when patients and the doctor hear my accents They they ask me are you Mexican? And I'm like, no, I'm from Puerto Rico I'm USA citizen if you want to know it And some patients ask me to leave doctors Well, I have one doctor that just Looked at me like he ignored me every rotation. So yeah, I feel that discrimination inclusive in Chicago that is have a big Hispanic population. So yeah That's an issue across IMGs across the country right? Whether you're Hispanic, or Indian, or Pakistani, or African, etc. Well, I had a similar situation when I was applying I had an interview in a place that was it was mostly either very Caucasian or African American and I received an invitation for an interview. I did all the process and went there and When I got to interview with the program director, the first thing that I was told it was why I was there Because I wasn't a good fit for the program because I had an accent. I was not able to to understand the population of that place So it's a real thing that we face especially when when they hear the accent So they tend to there tend to be a discrimination so Have you faced any? I would I would say in in those kinds of respects, right? It's really good to communicate with your medical school to let them know that these things are happening You know, it's it's not appropriate especially in an interview you know, that's that's telling of racial bias and You know Dr. Orozco shared this with me before and We are empowered with this data, right that the IMGs are Graduates who are working in the areas that American medical graduates do not want to work And so if you're going into a program and you're facing this discrimination we can turn that back You know if they're gonna say that it's likely that they're not gonna take you anyways, right? So maybe by offering the opportunity to teach them to say well based off of the data many of the non US IMGs or IMGs are the heart and soul of medicine in this area and More commonly international medical graduates Stay in the places that they train in and they provide care to the public sector They provide care to the poorer patients and the patients that Commonly your American medical graduates do not want to treat so it would be in your best interest to Listen to me regardless of my accent Either way, it's it's a win, right? You don't want to be in a program where there is systemic racism, but also if you are able to defend yourself Then also you may be able to make change in that program. That would be an incredible ripple effect I'm sorry. This has nothing to do with the topic For it I just wanted to know like now that step one is pass fail Are they gonna focus more on our DPAs or no? This is a big debate nationally because the answer is we're no one sure and that each program is remember when you get the large large volume of applications There has to be some statistical screening And I can tell you we even discussed that this morning about the bias of well if you're IMG you get screened out Automatically from certain programs, right and I won't even mention it that and how to address that kind of systemic Bias as well a priori, right? And so therefore then the question are what are the other predictors? that would what are the Proxies the predictors that should lead for us and in program to Put time and effort at screening further to then decide About interviewing and what happens is people are getting those things predictors up front with success later And it's not only that but if you've had to take your test several times, right because remember all programs Have to report back to the ACG me About Pat board pass rates, right? So if someone says yes, I've passed all my step scores great But I took this one three times. I took this one twice I took that one three times it gets viewed as a proxy of how well you're gonna do on your ITE or in training exam and psychiatry is the price psychiatry residency and later for your board Psychiatry residency and later for your boards and programs don't want that because that gets reviewed for accreditation So it's passing it on the first try now, but not just I passed it. Remember this is a hierarchy It's not binary good bad. It's it's how likely things right? So make sure they're passed passed on the first try If you can as well GPA is really looked at yes as a metric as a Predictor of success on these and we call it academic success in training exams and boards as well And then from there it depends on each of the programs what they start what else they look at like hey Let me glance at a letter of recommendation The smaller ones may look at your ps your personal statements, but not typically right or look at a couple other metrics, right? Because the metrics are the the rubrics are pretty much the same right scholarly activity Academic right scores and academic functioning scholarly activity clinical experience like shadow work experience volunteer experience letters of recommendation personal statement and Alignment right you stay away from fits right fit in the hr world We try to stay away from because it's been used for this kind of covert discriminatory purposes Like well why because you kind of don't fit here really and what they're trying to say is we don't like how you speak Or you don't have enough hair, you know, whatever I'm, joking. We have a lot of hair But it's so it's alignment with the values and the goals of the program. So you keep talking about alignment So at the front end, yes, it's the gpa is very important and your Your scores or your passing on the first try as it moves all to pass fail Thank you spending the time to make sure you pass the first time and pass. Well is good. Even if it means delaying graduation Well as soon as graduation hits that's when the time the clinical competency clock starts and in my experience Programs are more Less focused on how long it took you to complete medical school versus how long it's been since you've graduated That's correct that's remember that's discontinuity right that's a big one. Yeah, I wish I wish that's something that I knew So maybe it's a silly question, um Until which age can you apply for the residency? The question is because i'm with an american And we are living Fine in argentina I have my practice. I work for a clinic. I am a psychiatrist, but my husband being an american He wants to come back to america so It's kind of a dilemma for us What i'm gonna do if I go there and I cannot practice medicine, so that's why i'm here Like to investigate a little bit the maze that this question is sure. Yeah, I think You want to go ahead I have an answer to go ahead As you can see we are not so young like him I believe there is no a range of age for applying for a residency but For sure, they are going to see like a time frame of five years after medical school, but it doesn't mean I was practicing medicine for more than 15 years and I Got into a residency program But the first thing who you are is the first question that you have to do to yourself And also who what I'm going to offer First to that community when I want to practice you have to know that community If you feel because you are going to work for that community and you are going to serve that kind of people Is the second thing and also what I'm going to offer to the program That I am applying And you have to sell yourself what I am so important. What? what I why I'm going to do a different from you and then seeing a style like a Getting into kind of process for you in your In your benefits also you have to start like a Knowing or having like that kind of networking And kind of relationship when people know you To enhance your possibility to get into a residency. Is that important too? I don't know if I can so there is no specific age Required by either the acgme and as far as I know no programs have a specific age They won't tell you at least right informally, but generally if you're over 40, it makes it statistically much much less likely But more than that It's what happens when that first level of the screening right where you go and say oh my gosh This person graduated from medical school 12 years ago look at their gpa. Oh my gosh, they passed their scores blank And then you get into the second level of screening say oh, huh We'll see right. Oh, they're an img. Nope. They're out or no We're going to screen them in a more in-depth screening and then you start looking at all these other factors right of these things including the reasons why And a big one when you talk about program directors for individuals that have been in practice is their um Flexibility or educability right because no program wants an individual who's been in practice and comes in and say i've been here Um, I've been in practice for 12 years. I was a psychiatrist in colombia and now i'm here I know what i'm doing and I know because you're you're reverting but you're starting back as a trainee And that gets discussed quite a bit About that Educability right and how that well that person can flex and be back Into that role and grow and learn etc. Yeah, I I certainly know that even all the Beautiful pieces of paper I have like a master degree. It's nothing here. So I my mentality is like trying to know that I'm like a baby in the womb Basically if I decide to move here So I I just came from uh the lecture with dr. Vishal Madan and dr Pinsky who is the ceo of ecfmg? so one of the things I would tell you right away is to pursue ecgme certification um making sure that your medical school that you went to is ecfmg accredited And so if it is then pursuing that is your first step, right? um I know dr. Madan was talking about how we have several unmatched positions In subspecialties and we have a 99% match rate in psychiatry and general programs so one of the things that he's been strategizing and thinking about is to see whether the General psychiatrist can come in and pursue subspecialty training First and then sort of work their way backwards the challenges with that Is that you need to in order for you to be able to sit for the general psychiatry boards? you need to be trained in a General residency program in the united states or in canada so this is things that they're strategizing about let me address that right because if you look at the Acgme requirements because we did include that as a non-traditional pathway, right that Acgme allows for individuals that have What's called exceptionally qualified individuals who have done their training in another country? to Enter a fellowship first Child and adolescent being the classic example, right? without having Done their general psychiatry training now needless to say if you want to be board certified and Eligible and or certified in this country then you need to go on and move back and to get psychiatry training Which is a separate application? but in that exceptionally What happens is is that that's that happens but it's rare the programs do not announce it And most of the times it's very kind of idiosyncratic the program says oh my gosh, you're working here At least you worked here for years our research so and so oh my gosh We're going to accept you in child because we know you and and through this pathway we're going to allow you in etc So acgme does that's what he was alluding to right then that's called a non-traditional pathway into acceptance, right? And and very rare exactly very very rare and it it is a very arduous process for the residency program and so this is one of the reasons i'm going to track back to making sure that you have mentors and you increase your Exposure in areas that will help the american society of hispanic Psychiatrists may be a place where you have People who are more willing to see okay. Well, yeah, you're coming from argentina. Okay, you know I'm from argentina. Let me see if I can help And you know talking with different people to get you into the door So ashb is one of them, right I'm on the board of ashb, right? So thank you for that, right, but um, it's fun. We um There are pathways to the north Well, you could do an observership if you needed to to come in and see the us system and kind of start working there That's a process right and has to be strategic like dr. Singh has said it and and really well thought out Yeah So I am a pgy2 psych resident and my story is um It resonates a lot with this, uh this program this talk here um, I struggled to match for three cycles and um, a lot of that was because of my test scores And one thing that if I could offer my perspective on this um Your scores do not define who you are Okay, i'm Pretty sure, you know Hopefully all of us are passing our steps and you know if anybody here is struggling, I want you to know that You are more than your exams and You know from my perspective I was lucky enough to have actually dr. Singh as as a mentor um for a very long time ago And he was seeing the struggle that I was going through um to match and you know time and time again you keep trying you keep trying and Along the way you question a lot about who you are in the process you question you Double check yourself. You don't know if this is what you really want to do and you go into the darkest corner of your mind you know with your thoughts, so So One thing that i'm going to say to all of you Here who are struggling or or who are attempting residency? Is that it's not about what you know, it's about who you know and how you are in terms of your personality Your personality is huge. You got to be able to Bring to the table something that all the other residents can't bring You have to be able to Manage yourself in a situation that other people can't manage themselves in so I'll give you an example, you know, just because I didn't do well on my exams I worked twice as hard to get into a program and when I got on the floor finally I proved myself Not to anybody else not I didn't want to prove myself to the to the attending I didn't want to prove myself to the program director I wanted to prove myself to myself and a lot of The success that you'll gain comes from your failures and it will make you much stronger as a resident than people who Didn't get in the first time or who did get in the first time I should say And I want you all to have hope and continue to pursue What you want to pursue and don't let anyone try to take you out of that path and that's all I need to Say and if anybody has any We're gonna let dr. Singh take us home now, but thank you for that reflection and that and that Sharing your story because we think that's just as important as the information. We've been talking about here as well That's the substance that this discussion needs, right The doctor the only doctor who doesn't make it is the one who stops trying Indeed, right? Before we end I'd also like to mention IAPA, which is the the indo-american psychiatric association That's very well connected to the IMG caucus and so And so mentorship happens in many different places Just look up on google psychiatric association and you will be able to find You know An an ability for you to be able to connect and find the right mentor It is not easy to do this work but I do want to recognize The george tarjan award george tarjan was the first um APA It was the first IMG to become APA president and Year after year. There's an award that's given to IMGs who make significant contributions to enhance the integration of IMGs into american psychiatry And so I was grateful to meet Dr. Tony Fernandez who shared his uh his history and Um, I believe that he's instrumental in part of the IMG task force that's developing Some of the framework of what dr. Castellanos was mentioning um This is this is where it happens, right? And so i'm i'm very happy That we were able to have a fluid discussion i'm, very happy that You know, we got to share some experiences and I hope that You you really do? Appreciate the resources That have been offered we have on the citrus website collected a lot of these resources into different pdfs for medical students for For residents as well as early career psychiatrists and different things that we didn't talk about We didn't talk about the public service loan forgiveness. We didn't talk about some of the more intense immigration issues um Some of the resources that you can see are here and this is going to be a live document So based off of our discussion today, we'll make greater focus on some of these things and make it a little bit more robust um and this is uh, we're really really grateful that we had uh To share in this exchange today. So thank you all for your time. Appreciate it. Thank you You

International Medical Graduates

IMGs

American healthcare system

USMLE Step 3

observerships

externships

residency applications

FREIDA

ACGME core competencies

mentorship

psychiatry residency programs

discrimination issues

networking